Initiatives

Retention in Care: Mobile Teams Initiative

Background

In spring 2015, staff from the Washington AIDS Partnership and the D.C. Department of Health’s HIV/AIDS, Hepatitis, STD, and TB Administration met to discuss an issue the city was facing: how do you help people living with HIV to access and stay in care when traditional medical services have not worked for them? How do you help a person get to their doctor’s appointment when they do not have a car, are homebound, or have had a bad experience with their doctor and no longer want to come into a medical setting for services? When people face these and other barriers, how to do you help them lower their HIV viral load to undetectable levels, the gold standard of HIV care, and the primary mechanism for preventing further transmission of HIV?

To respond to this issue, the Washington AIDS Partnership secured over $1 million in funding from two national funders, the M·A·C AIDS Fund and the Bristol-Myers Squibb Foundation, for a three-year pilot. The Partnership developed a request for applications (RFA) for organizations providing medical care to HIV-positive individuals. The RFA’s focus was a novel one: tailor medical services to the unique needs of each patient, and meet them where they are. The two overarching goals were to help people living with HIV access and stay in care, and improve health outcomes. These goals would be reached by using innovative strategies such as medical visits in the home, evening hours, and providing care at non-traditional sites in the community. After a competitive application process, Whitman-Walker Health was selected to implement this pilot.

Implementation

Mobile Outreach Retention and Engagement (MORE) Team

After several months of ramp-up activities, including hiring and training staff, Whitman-Walker began providing services as part of the Mobile Outreach Retention and Engagement (MORE) initiative. The MORE team consisted of a physician’s assistant, two nurse practitioners, two care navigators, and a community health educator. The team provided medical evaluations, blood draws for lab tests, counseling, and supportive services in the home, at pop-up community sites, and on-site at Whitman-Walker. Patients also had access to other on-site services, including mental health, dental, and wellness appointments, and referrals to outside providers. Based on need, patients received different levels of support from the MORE team, from appointment reminders and care coordination with a patient’s current care team to home visits, transportation to specialty appointments, supportive services outside of normal working hours, and MORE staff attendance at patient appointments.

During the pilot, 319 individuals accessed and engaged in care, with over 5,900 medical and support visits. Among MORE patients with two HIV viral load tests, 80% either decreased their HIV viral load to undetectable levels, decreased their viral load in general, or maintained their HIV viral load at undetectable levels.

Patient Success Stories

“Tony” had recently stopped using drugs and had gotten housing when he started working with the MORE team. They worked intensely to help get him stabilized in his housing and with medical care. Since participating in MORE, his health has continued to improve and he is now very engaged in his own care. In fact, his phone has only two numbers saved in it and one of them is his MORE staff contact. He now asks specific, increasingly sophisticated questions about his health.

“Jesse,” a long-term Whitman-Walker patient, enrolled in MORE. He had a history of drug use and had completed a term at Bridgeback, a drug rehabilitation program, ten years ago. He was referred to MORE by one of Whitman-Walker’s care navigators after his HIV medication adherence and attendance to visits started to slip. The MORE team learned that the patient had struggled with depression to the point of considering suicide. In his first MORE visit, the team had to call emergency mental health crisis support for the patient who admitted to having a plan to harm himself. At his next follow-up visit, he agreed to a mental health intake so long as his new MORE care navigator came with him. The MORE team has been involved in his care for a number of months now, and they have seen the patient come out of his shell. He no longer carries himself with sadness or lack of confidence. He attends his therapy appointments, and has committed to realistic health goals for himself. He is on his way to being undetectable again and will soon celebrate 11 years of sobriety.

Future Plans

In summer 2018, MORE transitioned from a Washington AIDS Partnership initiative to a Whitman-Walker Health program.

The MORE initiative was made possible with funding from the Bristol-Myers Squibb Foundation and the M•A•C AIDS Fund. MORE’s evaluation efforts were funded in part by the Government of the District of Columbia, Department of Health, HIV/AIDS, Hepatitis, STD, and TB Administration.